Overview of Temporary Abdominal Closure Techniques
A laparotomy is a surgical procedure that opens up the abdomen. Usually, the surgeon will close the cut in the abdomen after the procedure. However, sometimes, situations arise where closing the cut becomes impossible, and the abdomen must be left open. This situation poses a significant problem and is linked to high death-rates of over 30%. Common reasons for leaving the abdomen open include swelling of the intestines due to inflammation (peritonitis), a condition where the pressure inside the abdomen is dangerously high (abdominal compartment syndrome), and during emergency procedures to control bleeding in trauma patients.
When the abdomen is left open, surgeons use methods known as Temporary Abdominal Closure (TAC) techniques. These techniques provide a temporary solution until it’s safe and possible to close the cut in the abdomen. There are various TAC methods that are used, each designed to tackle the challenges presented when the abdomen is left open. These methods include dressing the wound with a special dressing that creates a gentle vacuum (negative pressure wound therapy), using stitches to hold the cut edges together (dynamic retention sutures), using a special type of covering (Bogotá bag, mesh, or sheet), loosely packing the wound, pulling the skin together, or using a zipper-like device.
Each method has its unique advantages in maintaining tension on the edges of the cut while dealing with different situations. It’s crucial for medical professionals to understand these techniques and know how to use them. If the abdomen isn’t closed properly after being left open, patients are at risk of developing serious complications such as ventral hernias (a type of hernia that occurs at the site of the surgical scar).
While the decision on which method to use should be based on the individual patient’s condition and risks, there isn’t much scientific evidence comparing the effectiveness of the different techniques. This is an area that requires more research. The next parts of the original article go into more detail about how these techniques work, how they are used, and what complications can occur.
Anatomy and Physiology of Temporary Abdominal Closure Techniques
When a patient is unstable during emergency stomach surgery, the surgeon might need to temporarily close up the belly area. This helps stabilize the patient’s condition. The key parts involved in this temporary closure include:
- Skin – the outermost layer that covers and protects the body.
- Subcutaneous tissue – the layer of fat and soft tissues that provide padding, insulation and stores energy.
- Superficial fascia – a delicate, thin layer that helps connect the skin to underlying tissues.
- ‘Linea alba’ or midline of the rectus sheath – a strip of strong, fibrous tissue in the middle of the stomach muscles.
- Transversalis fascia – another layer of strong tissues that coats the inside of the belly area.
- Preperitoneal space – the area between the muscle layer and the abdominal cavity.
- Peritoneum – the innermost layer that lines the abdominal cavity.
An important goal in temporary belly closure is to avoid the side muscles pulling apart, to ensure the ‘linea alba’ or midline can be stitched back together when the time comes.
Why do People Need Temporary Abdominal Closure Techniques
Temporary abdominal closure, or TAC, is a procedure that a doctor may use in some critical surgical situations. They may choose to use this treatment when they cannot close the abdominal wall at the end of a surgery, or if the closure could cause more harm. These situations, when the doctor might decide to leave the abdomen open, include:
- Severe abdominal infection: If an infection in the belly is so severe that it can’t be managed with a single surgery, TAC may be necessary. This situation can happen with an infected pancreas or other serious infections in the abdomen.
- Trauma and bleeding: If someone has experienced severe injuries, this procedure may be used as part of damage control surgery, which aims to control excessive bleeding and prevent contamination from abdomen’s contents.
- Ischemic gut and second-look surgery: Patients with bowel that has lost its blood supply may need TAC. This approach allows doctors to leave the belly open and later check the health of the bowel, even potentially removing additional sections if required.
- Abdominal compartment syndrome: This is a situation where a dangerous amount of pressure builds inside the abdominal cavity. The surgeon might need to open the abdomen to relieve this pressure using TAC. This relief could be done as a preventive measure in some cases where the pressure is very high but hasn’t yet caused organ dysfunction.
- Transplantation with size discrepancy: TAC may be necessary after a transplant if the size of the new organ and the recipient’s abdomen don’t match up correctly.
In summary, TAC is a very helpful tool that allows doctors to manage a range of different challenges. It’s a temporary measure that allows the doctor to keep the abdomen safely open until it can be closed up later. The decision to use TAC will be determined by specific circumstances of each patient and how stable they are for future surgical intervention as judged by their surgeon.
When a Person Should Avoid Temporary Abdominal Closure Techniques
While TAC (temporary abdominal closure) is a useful way to close a surgical wound temporarily, it’s not always the best choice. In certain cases, doctors should not use this technique:
– If the patient’s condition is getting better during the initial surgery, there might be the possibility of closing the wound right away. In this case, TAC might not be needed.
– If the doctors can stop any bleeding and clean any contamination during the initial surgery, and they don’t need to use quick methods for preventing further damage, then TAC might not be necessary.
– In situation where using TAC might make the patient’s condition worse or lead to other unexpected problems, doctors should think about other methods for closing the wound.
– If it’s possible to close the wound right away without putting the patient’s health at risk, then TAC should be avoided.
– If there are no signs of abdominal compartment syndrome (a dangerous condition where pressure builds up in the abdomen) or significantly high pressure inside the abdomen, it might not be necessary to use TAC as a preventative measure.
These reasons show how important it is for doctors to make decisions based on each patient’s specific situation and needs. They need to think about the potential risks and benefits of using TAC, take a close look at the patient’s stability and ongoing surgical needs, and consider whether it’s likely they could close the wound right away.
Equipment used for Temporary Abdominal Closure Techniques
TAC, or Temporary Abdominal Closure, needs certain special tools to deal with an open stomach area properly. The choice of tools can change depending on what the surgeon likes to use, the specific medical situation, and the exact TAC method that’s being used.
Who is needed to perform Temporary Abdominal Closure Techniques?
To carry out a TAC or temporary abdominal closure, a team of medical professionals work together. The members of this team can vary depending on the method used and your specific health circumstances. Here are some of the key team members that are usually involved in TAC:
– A doctor who specializes in surgery, also known as a ‘surgeon.’
– A surgical assistant who assists the surgeon.
– A scrub technician or scrub nurse who is responsible for sterilizing and handing instruments to the surgeon during the procedure.
– Operating room nurses who make sure that everything in the operating room runs smoothly.
– An anesthesiologist or nurse anesthetist, who is a specialist in giving the medicine that makes you go to sleep for the procedure.
Depending on the method of TAC used, a wound care specialist might be needed. They could be involved in applying and managing a vacuum system, a technique called negative pressure wound therapy. This therapy helps the wound heal by reducing pressure and helping remove any excess fluid.
After the operation, nurses who work in the intensive care unit are responsible for looking after you and helping you recover.
How is Temporary Abdominal Closure Techniques performed
When a surgeon chooses to leave your belly exposed after surgery, they temporarily cover the area with a technique called TAC, or “Temporary Abdominal Closure”. This helps control any fluid loss and keeps tension across the large muscles in your tummy so that they don’t shrink or pull back, which is known as a “loss of domain”. Over the past 30 years, the way surgeons manage this type of open belly surgery has improved dramatically. However, even though various techniques of TAC exist, the best method is still not clearly defined as the perfect fit for every patient is usually different. Here are some of the techniques:
The first technique is what’s called “Simple Packing”. Here, the surgeon places soft, wet bandages directly on the organs in your tummy without stitches, leaving your belly open to let fluid drain out. The dressings are changed, and your belly is cleaned every day as you recover in the intensive care unit.
The second technique is known as “Skin-Only Closures”. In this method, the surgeon uses your skin to keep your belly stable and contain your organs. They do this by either using a series of clips on your skin, or by stitching your skin closed. Despite the benefits of being quick, affordable, and easy to do, these methods come with increased risks like your organs pushing out through your stitches, injuries to your skin, infections, and more. Considering these risks, these techniques are not commonly used today.
The third method involves sutures referred to as “Dynamic Retention Sutures” or an “Abdominal Reapproximation Anchor (ABRA®)”. These involve plastic tubes inserted through the large muscles of your stomach which are held in place. These tubes can be tightened to minimize loss of domain in the open abdomen. They’re pretty straightforward to apply, but they can potentially cause bowel pressure and may risk formation of an abdominal compartment syndrome.
The fourth technique, known as “Silo Techniques”, involves sewing a large, sterilized bag to the large muscles in your stomach, or your skin. This bag acts as a barrier to hold in your organs, but it can be time-consuming to apply and makes fluid control difficult. Additionally, the procedure has limitations, including not preventing the muscles of the stomach from pulling back and restricting effective removal of abdominal fluids.
The final technique uses “Mesh”, either permanent or absorbable, to manage an open abdomen. Permanent synthetic mesh offer protection to the tissues of your stomach, prevent the muscles of your stomach from pulling back and reduce the chances of a hernia. However, these meshes can potentially cause complications like wrinkling, infection, hernia, mesh extrusion, and enteric fistula. Absorbable meshes are resistant to infection and pliable, but they can lead to complications like fistula formation and abscesses.
All these methods have their own advantages and disadvantages, so your surgeon will evaluate your situation carefully to choose the method that’s best for you.
Possible Complications of Temporary Abdominal Closure Techniques
Temporal abdominal closure, or TAC, is a type of medical procedure that can be helpful in certain situations. However, like all surgeries, it carries some possible risks. These risks can depend on the way the procedure is done and the patient’s overall health. Here’s what you might need to know about potential complications from TAC:
– Infection: With any stomach surgery, there’s a chance that the area where the surgery was performed might get infected. One study showed more fungal infections in the belly in people who had TAC surgery after a trauma incident.
– Trouble with closing the stomach area (Delayed primary fascial closure): After TAC surgery, doctors aim to close up the stomach area. But this can be difficult if there’s a lot of swelling, an infection, or a lot of tissue damage.
– A problem with the bowel (Enteric fistula): Sometimes, unusual connections can form between the bowel and other body parts. This can cause what’s known as an enteric fistula. This condition can be tricky to manage because the bowel’s fluid seeps into the wound, preventing it from healing properly. However, the use of Negative Pressure Wound Therapy (NPWT), a popular treatment method, is generally seen to lower the risk of this condition than other techniques.
– Bleeding: There’s a possibility of bleeding either during or after TAC surgery. That’s why it’s so important for the bleeding to be controlled during the surgery and for patient monitoring afterwards.
– Wound reopening (Wound dehiscence): The surgical wound can sometimes reopen, especially if there’s too much pressure inside the belly, if wound healing isn’t going well, or if the patient isn’t fit for scarring.
– A bulge in the abdomen (Hernia): If the doctor can’t stitch up the belly right away, hernia might happen. The best way to avoid this is to close the surgery area within 10 to 14 days. Some studies show a high rate of hernia development later on after open stomach surgeries.
– Adhesions: Sometimes, the organs inside the belly can stick to the abdominal wall. This might cause problems during future surgeries.
– A very full belly (Abdominal Compartment Syndrome): This is a condition where there’s too much pressure inside the belly, which can affect the function of various organs. Sometimes, TAC surgery or other underlying health problems can contribute to this issue.
– Pain: The patient may feel pain or discomfort associated with the open belly and the TAC devices. Pain management is a crucial part of care after surgery.
– Complications tied to specific TAC techniques: Different methods of TAC have their unique risks. For instance, issues like device malfunction, skin death, or adhesions might be tied to specific procedures.
– Complications from prolonged open abdomen: Leaving the stomach area open for too long might cause issues like fluid and salt imbalances, breathing problems, and difficulty maintaining the belly condition.
Healthcare providers need to stay alert, watch over patients closely, and address complications without delay to ensure the best results after TAC. The method of TAC, timing, and ongoing patient care all work together to prevent complications and ensure a successful outcome.
What Else Should I Know About Temporary Abdominal Closure Techniques?
The technique called Temporary Abdominal Closure (TAC) is very important in treating a range of serious abdominal (stomach area) conditions. These can include trauma, serious infections, and complications after abdominal surgery. TAC is a strategic method used to control severe bleeding, prevent the spread of contamination, and alleviate a condition known as abdominal compartment syndrome, which happens when there’s too much pressure in your abdomen. This technique provides a staged and controlled setting for surgical procedures.
When severe infections like infected pancreatic necrosis (a serious inflammation of the pancreas) or peritonitis (inflammation of the inner wall of the abdomen) occur, TAC allows for repeated access to the area, cleaning of the wound (debridement), and draining, ensuring the infection is effectively controlled. It also assists in damage control surgery, enabling a phased approach in trauma scenarios to address immediate life-threatening issues before the surgical wound is closed securely.
TAC is particularly valuable in managing conditions related to blocked blood flow to the bowel (ischemic bowel conditions). It offers a “second-look” option which allows doctors to check the condition of the bowel and prevent unnecessary extensive removal of sections of the bowel. Overall, TAC is crucial in improving patient outcomes, increasing survival rates, and providing a personalized approach to complex abdominal issues.